BACKGROUND:Early repair of the ruptured cerebral aneurysm (RRCA), preferably within 24 h of onset, is endorsed by clinical guideline as the preferred management strategy for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, a comprehensive picture of this guideline-recommended usage in contemporary clinical practice is not available. AIMS:This study aimed to characterize trends over time and practice variation in the implementation of an early RRCA strategy among patients with aSAH in a large, national representative data. METHODS:Using data from the 2012-2019 National Inpatient Sample, we measured trends in the proportion of early RRCA, defined as within day 1 of admission, overall, and by demographic and geographical subgroups. In addition, we created multilevel regression models to quantify hospital-level variation in the early RRCA rates. RESULTS:We identified 82,615 aSAH hospitalizations (mean age = 56.1 years; 68.9% women) undergoing RRCA and, among these, 84.0% (95% confidence interval (CI) = 83.4-84.7%) receiving early RRCA. The proportion of early RRCA increased steadily from 82.5% in 2012 to 85.8% in 2019 (p for trend <0.001). The proportion of patients receiving early RRCA across geographic regions ranged from 78.7% to 87.9%, with a median (interquartile range (IQR)) of 84.2% (83.0-86.1%). In contrast, the delivery of early RRCA varied widely among hospitals, with a median (IQR) rate of 86.1% (75.0-100.0%) and a range from 0% to 100.0%. The median odds ratio for the early use of RRCA treatment was 1.24 (95% CI = 1.21-1.27) in 2019, indicating 24% increased odds of implementing early RRCA if moving from a lower-use to a higher-use hospital. CONCLUSIONS:Most patients in the United States with aSAH received early RRCA treatment and exhibited an upward trend over the recent 8-year period. However, substantial variation in access to early RRCA was observed across population subgroups, particularly at the hospital level. Future efforts are necessary to identify further sources of this variation and to develop initiatives that could represent an opportunity to optimize guideline-based quality of care in aSAH management. DATA ACCESS STATEMENT:The data are available from the corresponding author upon reasonable request following completion of onboarding and verification procedures as specified by the HCUP.

Background Stereotactic radiosurgery (SRS) treatment planning requires accurate delineation of brain metastases, a task that can be tedious and time-consuming. Although studies have explored the use of convolutional neural networks (CNNs) in magnetic resonance imaging (MRI) for automatic brain metastases delineation, none of these studies have performed clinical evaluation, raising concerns about clinical applicability. This study aimed to develop an artificial intelligence (AI) tool for the automatic delineation of single brain metastasis that could be integrated into clinical practice. Methods Data from 426 patients with postcontrast T1-weighted MRIs who underwent SRS between March 2007 and August 2019 were retrospectively collected and divided into training, validation, and testing cohorts of 299, 42, and 85 patients, respectively. Two Gamma Knife (GK) surgeons contoured the brain metastases as the ground truth. A novel 2.5D CNN network was developed for single brain metastasis delineation. The mean Dice similarity coefficient (DSC) and average surface distance (ASD) were used to assess the performance of this method. Results The mean DSC and ASD values were 88.34%±5.00% and 0.35±0.21 mm, respectively, for the contours generated with the AI tool based on the testing set. The DSC measure of the AI tool’s performance was dependent on metastatic shape, reinforcement shape, and the existence of peritumoral edema (all P values <0.05). The clinical experts’ subjective assessments showed that 415 out of 572 slices (72.6%) in the testing cohort were acceptable for clinical usage without revision. The average time spent editing an AI-generated contour compared with time spent with manual contouring was 74 vs. 196 seconds, respectively (P<0.01). Conclusions The contours delineated with the AI tool for single brain metastasis were in close agreement with the ground truth. The developed AI tool can effectively reduce contouring time and aid in GK treatment planning of single brain metastasis in clinical practice.

Introduction: Constipation is one of the common poststroke complications that directly affect the patients’ quality of life in patients with intracerebral hemorrhage (ICH), which has not been paid enough attention. Objective: This study investigates constipation’s clinical characteristics and its risk factors in ICH patients driven by the electronic medical records of nursing care. Methods: This retrospective chart review investigated patients with acute spontaneous ICH admitted at a tertiary care center from October 2010 to December 2018. Poststroke constipation was defined as a first stool passage occurring after 3 days postadmission and the use of enemas or laxatives after ICH. The associations between constipation present and potential factors were evaluated. Results: Of 1,748 patients, 408 (70.3% men, mean age 58 ± 14 years) patients with poststroke constipation were identified. After adjusting for potential confounding variables, the risk factors independently associated with poststroke constipation are admission Glasgow Coma Scale score (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.44–0.88; p = 0.007), use of mechanical ventilation (OR 3.74, 95% CI 2.37–5.89, p < 0.001), enteral nutrition (OR 2.82, 95% CI 1.85–4.30, p < 0.001), hematoma evacuation (OR 2.10, 95% CI 1.40–3.16; p < 0.001), opioid analgesics (OR 1.86, 95% CI 1.32–2.62; p < 0.001), sedation (OR 1.83, 95% CI 1.20–2.77; p = 0.005), and vasopressors (OR 1.81, 95% CI 1.26–2.61; p = 0.001) in order. Similar associations were observed in the prespecified length of the stay subgroup. Patients with constipation were associated with a longer hospital stay length (2.24 days, 95% CI 1.43–3.05, p < 0.001) but not with in-hospital mortality (OR 1.05, 95% CI 0.58–1.90, p = 0.871). Conclusions: Our findings suggested that risk factors influence the absence of constipation after ICH with the synergy of different weights. The occurrence of constipation likely affects a longer length of stay, but not in-hospital mortality. Future prospective investigations are warranted to validate our findings and identify the optimal management of constipation that may improve the quality of life in patients with ICH.

Abstract Objective Published studies have shown hyperglycemia is associated with poor outcome in patients with intracerebral hemorrhage (ICH). However, the association between blood glucose and outcome in surgical ICH patients is unknown. In the present study, we sought to evaluate the predictive value of admission and postoperative glucose for 30-day outcome in patients with ICH undergoing neurosurgical treatment. Methods We retrospectively studied acute ICH patients who underwent neurosurgical treatment at a tertiary care hospital between January 2013 and December 2018. Patient demographics, clinical and radiological data were recorded. Serum glucose was measured at admission and after surgery. Receiver operating characteristic curves were used to evaluate the predictive power of important predictors. Multivariable logistic regression analyses were performed to identify independent factors of 30-day mortality. Results The present analysis included 344 patients (66.3% male, mean age 59.1 years). Elevated admission glucose (odds ratio [OR] 1.11; 95% confidence interval [CI] 1.03–1.20; p = .007) and postoperative glucose (OR 1.18, 95% CI 1.06–1.31; p = .003) were independently associated with increased 30-day mortality. There was no significant difference in predictive ability between admission glucose (area under curve [AUC] 0.668, 95% CI 0.608–0.719) and postoperative glucose (AUC 0.631, 95% CI 0.573–0.687) for 30-day death (p = .467). Multivariate logistic regression analysis also identified that admission Glasgow Coma Scale (GCS) score (p < .001), initial hematoma volume (p = .001), and the presence of intraventricular hemorrhage (IVH, p = .002) were independently predicted 30-day mortality. Conclusions For patients with ICH who received neurosurgical treatment, admission GCS score, initial hematoma volume, presence of IVH, admission and postoperative glucose level are independently associated with 30-day mortality. Admission and postoperative glucose may apply as predictors and targets for surgical ICH patients.

Background Parasellar meningioma is a common benign tumour in brain. Both surgery and radiosurgery are important treatment modalities for this tumour. The study was designed to investigate whether prior surgery would affect treatment outcomes of patients with parasellar meningiomas after management with Gamma Knife radiosurgery. Methods A total of 93 patients who received Gamma Knife surgery were included in this retrospective study. There were 30 males and 63 females, with a median age of 48.6 years (range, 15.2–78.7 years). Prior surgery was performed in 45 patients. The median tumor volume was 5.02 cm 3 (range 1.07–35.46 cm 3 ) and median marginal dose was 12 Gy (range 10–15 Gy). The mean imaging follow-up and clinical follow-up periods were 40.7 and 52.7 months, respectively. Results In the group without prior surgery, 31 patients had improvement of preexisting symptoms; and in the group with prior surgery, 20 patients were noted to improve. The difference in symptom improvement between the two groups reached statistical significance ( P = 0.009). Patients with prior surgery were more likely to have stable symptoms after Gamma Knife surgery ( P = 0.012). Tumor recurrence was reported in 8 patients out of 45 patients with prior surgery, and 3 patients out of 48 patents without prior surgery ( P = 0.085). After Gamma Knife surgery, 5 and 4 patients in two groups developed new neurological symptoms, respectively ( P = 0.651). Cox regression analysis identified follow-up period as prognostic factor of progression-free survival. Ordinal logistic regression analysis identified surgery prior to Gamma Knife surgery as an unfavorable factor of symptom change. Conclusion Gamma Knife radiosurgery provided long-term effective tumor control and better symptom recovery compared with those with prior surgery. Patients with surgery before Gamma Knife radiosurgery were more likely to have stable symptoms. Further analyses indicated that long follow-up is essential to determine the efficacy of radiosurgery for parasellar meningiomas. Further study needs to include more patients with longer follow-up to draw a more solid conclusion.

Superficial siderosis (SS) of the central nervous system is a disease characterized by deposition of hemosiderin in the leptomeninges (arachnoid and pia mater) due to chronic intradural bleeding. One of the etiologic mechanisms proposed is a dural breach secondary to trauma with a consequent arachnoidocele in contact with an exuberant venous plexus. We describe a unique case of clival arachnoidocele treated by an endoscopic endonasal approach and closure of the defect with fat and nasoseptal flap.A 35-year-old man with a history of severe head trauma 20 years ago presented with hearing deficit and a mild motor ataxia impairing gait. Magnetic resonance imaging disclosed hemosiderin deposition throughout the brain cortical layer and in the cerebellum, affecting the dentate nucleus as well. A computed tomography revealed an osteolytic formation in the clivus, involving the inner bone table and bone marrow. The patient was then submitted to an endoscopic endonasal transclival approach to close the defect.SS may be a result of several etiologies generating repetitive meningeal bleeding. Our patient had the diagnosis of posttraumatic clival arachnoidocele and SS probably related to trauma with some dural injury. An endoscopic endonasal approach with tear reconstruction is feasible and successful to address clival arachnoidoceles and, in this case, to avoid progression of the SS.

Objective: The association between angiotensin II type 1 receptor ( AGTR1 ) gene A1166C polymorphism and cancer risk has been investigated in many studies. However, the results have been inconclusive. A meta-analysis was performed to obtain a more precise estimation of the relationship. Methods: The PubMed and China National Knowledge Infrastructure databases were searched for published literature. Odds ratios (ORs) with 95% confidence intervals (CIs) were used to assess the strengths of association. Results: Ten studies, including 1553 patients and 1904 controls, were included in the meta-analysis. Overall, there were no significant associations between the AGTR1 gene A1166C polymorphism and cancer risk in the general population (CC vs AA: OR = 1.09, 95% CI = 0.50–2.37; AC vs AA: OR = 1.54, 95% CI = 0.81–2.91; dominant model: OR = 1.46, 95% CI = 0.77–2.79; recessive model: OR = 1.12, 95% CI = 0.84–1.49). In a subgroup analysis by nationality and cancer type, the results also showed no association between this polymorphism and cancer risk. Conclusions: This meta-analysis demonstrated that the AGTR1 gene A1166C polymorphism does not appear to be related to the risk of cancer.

HomeStrokeVol. 49, No. 2Letter by Liu et al Regarding Article, "Thrombolysis in Postoperative Stroke" Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Liu et al Regarding Article, "Thrombolysis in Postoperative Stroke" Fujun Liu, MD, Wei Chen, MD and Jing Chen, MD, PhD Fujun LiuFujun Liu Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu , Wei ChenWei Chen Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu and Jing ChenJing Chen Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu Originally published28 Dec 2017https://doi.org/10.1161/STROKEAHA.117.019761Stroke. 2018;49:e36To the Editor:We have read with great interest the article by Voelkel et al1 investigating the safety of intravenous thrombolysis (IVT) in patients with postoperative stroke. The authors proposed that IVT may be administered safely in postoperative patients as off-label use after appropriate risk–benefit assessment. However, after a detailed analysis of this article, we have some opinions about the study, which need to communicate with the authors because the article directly relates to my clinical interest.First, in results section, we noted that intracranial hemorrhage (ICH) occurred in 9.7% (13 of 134) and was asymptomatic in all cases. However, it is unclear when bleeding complications occurred after IVT in cases with postoperative stroke? If we knew the exact time, this might be meaningful because it provided important data on predicting when the ICH will likely happen, especially to patients whose postoperative stroke are asymptomatic. In addition, asymptomatic ICH was not well defined. Furthermore, it is not clear how asymptomatic ICH is evaluated in their article.1 This information might be helpful to the readers to know how to assess asymptomatic ICH after recombinant tPA (tissue-type plasminogen activator) administration, which would be of great clinical significance.Second, the primary outcome measured in their article was surgical site hemorrhage (SSH).1 Hence, a postoperative correct evaluation of the SSH is extremely important. In this article, the authors mentioned that the bleeding severity of SSH was performed according to the Valve Academic Research Consortium.1 However, detailed information about evaluation of the SSH was unknown. For example, if a patient had a diagnosis of stroke after 2 to 3 days of operation, and the patient was bleeding in the surgical area caused by surgery and received IVT, how is the SSH evaluated in this situation? In particular, this occurred when the reduction of hemoglobin levels was slightly. If this primary outcome was not evaluated correctly, the rate of SSH might be changed in their results section.Third, several other important risk factors, such as blood pressure, cerebral microbleeds, and renal impairment, should also have been controlled for more reliable outcomes. The increased blood pressure may induce hemorrhagic transformation in patients with ischemic stroke. Xu et al2 found that there was a significant difference between the hemorrhagic transformation and nonhemorrhagic transformation group (P<0.05) in the level of mean systolic pressure 24 hours after thrombolysis. They concluded that mean systolic pressure ≥140 mm Hg was a risk factor for hemorrhagic transformation after thrombolysis in patients with acute cerebral infarction. Furthermore, Charidimou et al3 implemented a meta-analysis on the relationship between cerebral microbleeds and post-thrombolysis ICH risk in acute ischemic stroke, and their results showing an increased risk of symptomatic ICH after thrombolysis for acute ischemic stroke in patients with cerebral microbleeds. Renal impairment can lead to symptomatic ICH after thrombolysis for ischemic stroke too. Tütüncür et al4 reported the association between renal impairment and ICH after IVT. They revealed that severe renal impairment is associated with ICH after IVT with recombinant tPA administration.Finally, we would like to express our respect to authors for their interesting and meaningful study. We hope the items mentioned above would add the value of the well-written article by Voelkel et al1 regarding the thrombolysis in postoperative stroke.Fujun Liu, MDWei Chen, MDJing Chen, MD, PhDDepartment of NeurosurgeryWest China Hospital of Sichuan UniversityChengduDisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 4 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited.References1. Voelkel N, Hubert ND, Backhaus R, Haberl RL, Hubert GJ. Thrombolysis in postoperative stroke.Stroke. 2017; 48:3034–3039. doi: 10.1161/STROKEAHA.117.017957.LinkGoogle Scholar2. Xu X, Li C, Wan T, Gu X, Zhu W, Hao J, et al. Risk factors for hemorrhagic transformation after intravenous thrombolysis in acute cerebral infarction: a retrospective single-center study.World Neurosurg. 2017; 101:155–160. doi: 10.1016/j.wneu.2017.01.091.CrossrefMedlineGoogle Scholar3. Charidimou A, Shoamanesh A, Wilson D, Gang Q, Fox Z, Jäger HR, et al. Cerebral microbleeds and postthrombolysis intracerebral hemorrhage risk updated meta-analysis.Neurology. 2015; 85:927–924. doi: 10.1212/WNL.0000000000001923.CrossrefMedlineGoogle Scholar4. Tütüncü S, Ziegler AM, Scheitz JF, Slowinski T, Rocco A, Endres M, et al. Severe renal impairment is associated with symptomatic intracerebral hemorrhage after thrombolysis for ischemic stroke.Stroke. 2013; 44:3217–3219. doi: 10.1161/STROKEAHA.113.002859.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails February 2018Vol 49, Issue 2 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.117.019761PMID: 29284729 Originally publishedDecember 28, 2017 PDF download Advertisement SubjectsCerebrovascular Disease/StrokeIntracranial HemorrhageIschemic Stroke